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Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by failing to repair and seal penetrations to prevent the spread of fire and smoke. This failure affected patients, staff and visitors in 3 of 17 smoke compartments in the East Campus.

Findings:

During a tour of the facility with the Plant Maintenance Manager, Plant Operations Manager, Director of Public Safety and Safety Officer, from July 9, 2012 through July 12, 2012, the facility walls and ceilings were observed.

East Campus on 7/9/12
1. At 4 p.m., there was an approximately 1/2 inch penetration around two blue wires in the left side of the ceiling in the Pediatrics Medication Room.

East Campus on 7/10/12:
2. At 9:45 a.m., there was an approximately 1 inch unsealed penetration around blue and white wires, in the right comer of the ceiling, in the NCU (Nursing Care Unit) copy machine room.

3. At 9:54 a.m., there were two approximately 1/2 inch penetrations in the left side of the ceiling in the Payroll office, located in the Finance Department.

Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke, as evidenced by corridor doors that failed to latch or were obstructed from closing. This affected 4 of 20 smoke compartments in the Tower Building and 3 of 17 smoke compartments in the East Campus. This failure had the potential to allow the spread of smoke, which could result in potential harm to patients, staff and visitors.

Findings:

During the facility tour with the Facility Management Director, Director of Quality Management, Director of Public Safety, Plant Operations Manager and Plant Maintenance Manager from July 9, 2012 through July 11, 2012, the corridor doors were observed.

East Campus on 7/9/12
1. At 3:32 p.m., the door to Room 911 failed to latch when closed.

East Campus on 7/11/12
2. At 9:24 a.m., the door to Room 718 failed to latch when closed.

3. At 9:38 a.m., the door to Room 703 failed to latch. The door hit the side of the door jam and could not be fully closed.


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Tower on 7/9/11
4. At 1:32 p.m., the door to Room 309 did not close and latch when tested. The door struck the door frame and was obstructed from closing.

At 1:33 p.m., during an interview, the Facilities Management Director stated "The door is hitting the door frame."

5. At 2:55 p.m., the CT supply room door, on the first floor, was equipped with a self closing device. The door did not latch when tested. Three attempts were made without the door latching.

At 2:56 p.m., the Plant Manager stated during an interview "the door is not latching."

East Campus on 7/10/12
6. At 9:28 a.m., the door to the Intake Office, in Behavioral Health East, was equipped with a self closing device. The door did not latch in five attempts.

At 9:29 a.m., the Plant Manager stated during an interview "the door is not latching."

Tower on 7/10/11
7. At 1:49 p.m., the door to Room 6 in ICU 1 was impeded from closing. A laundry cart was in front of the door.

8. At 2:22 p.m., the door to ACU-2, in Outpatient Surgery, second floor, was impeded from closing. A bed was in front of the door.

Based on observation, the facility failed to ensure horizontal exit doors, on magnetic hold open devices, release and close automatically during activation of the fire alarm system. This was evidenced by a horizontal exit door that failed to release from its magnetic device. This affected 1 of 17 smoke compartments in the East Campus Building. This failure could result in the spread of fire and smoke from one compartment to another.

Findings:

During fire alarm system testing, with the Plant Maintenance Manager, Plant Operations Manager, Facility Management Director, and Director of Public Safety, on July 11, 2012, the doors on magnetic devices were observed.

East Campus on 7/11/12
At 10:20 a.m., the corridor door to the Activity room for Neuro Care West failed to release from its hold open device, after activation of the fire alarm system.

Based on observation and interview, the facility failed to maintain their exit signs in accordance with regulations. This was evidenced by an exit sign that failed to illuminate when tested on battery power. This could delay egress in 1 of 5 smoke compartments on the third floor in the Tower Building, causing potential harm to patients and staff in the event of a fire emergency.

NFPA 101 Life Safety Code, 2000 edition
7.10.5 Illumination of Signs.
7.10.5.1* General. Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests
shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency
lighting equipment that automatically performs a test for not less than
30 seconds and diagnostic routine not less than once every 30 days
and indicates failures by a status indicator shall be exempt from the
30-day functional test, provided that a visual inspection is performed
at 30-day intervals.

Findings:

During a tour of the facility with the Facilities Management Director, and Director of Quality Management, on July 9, 2012, the exit signs were observed in the Tower.

Tower on 7/9/12
At 1:50 p.m., the exit sign near Room 306 did not illuminate when the test button was pressed.

During an interview at 1:51 p.m., the Facilities Management Director confirmed the sign did not light up when the test button was pushed.

Based on observation and interview, the facility failed to maintain the integrity of the smoke barrier walls. This was evidenced by penetrations in 4 of 20 smoke barrier walls in the Tower Building. This had the potential to allow the spread of fire and smoke, during a fire.

NFPA 101, Life Safety Code (2000 Edition)
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with facility staff, on July 9, 2012, the smoke barrier walls were observed in the Tower building.

Tower on 7/9/12
1. At 2:23 p.m., there was an approximately 1 inch penetration around a conduit, in the smoke barrier wall next to Room 214. The area inside of the conduit was not sealed. This was confirmed by the Plant Maintenance Manager during the survey.

2. At 2:32 p.m., there was an approximately 1 inch by 2 inch penetration in the center of the smoke barrier wall located outside of NICU.

3. At 2:48 p.m., there were penetration around four conduits in the Surgery entrance side of the smoke barrier wall. This was confirmed by the Plant Maintenance Manager during the survey.


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4. At 1:59 p.m., there was an approximately 3/4 inch unsealed conduit in the North smoke barrier wall, above the fire doors, on the third floor near the service elevator C.

Based on observation and interview, the facility failed to maintain its smoke barrier (cross-corridor) doors to prevent the spread of smoke and fire. This was evidenced by smoke barrier fire doors that were equipped with latching hardware, and failed to latch when tested. This deficient practice could result in the spread of smoke and fire. This could affect patients, staff and visitors in 4 of 17 smoke compartments on the East Campus and 1 of 20 smoke compartments in the Tower Building.

Findings:

During fire alarm testing with facility staff, on July 10, 2012 and July 11, 2012, the smoke barrier doors were observed.

East Campus, First floor
1. At 9:53 a.m., the North leaf of the smoke barrier doors near Birth Records, on the first floor, did not latch when tested by the Plant Maintenance Manager.

At 9:54 a.m., the Plant Maintenance Manager stated during an interview, "the latching mechanism is sticking."

East Campus, First Floor
2. At 10:42 a.m., the Activity Therapy smoke barrier door in BHS East, did not latch when tested by the Plant Maintenance Manager.

East Campus, First floor
3. At 10:50 a.m., the East smoke barrier door, near the first floor Gym, did not latch when tested by the Plant Maintenance Manager.

Tower, First floor
4. At 2:30 p.m., the West smoke barrier door, at the South Lobby entrance, did not latch when tested by the Plant Maintenance Manager.

Based on observation, the facility failed to maintain the gift shop storage room door to resist the passage of smoke. This was evidenced by one door that was impeded from closing. This affected 1 of 6 smoke compartments on the first floor of the Tower Building and had the potential to allow the spread of smoke and fire.

Findings:

During the facility tour with staff, on July 9, 2012, the Tower gift shop storage room was observed.

At 3:26 p.m., the door to the storage room was impeded from closing. A brown rubber wedge was placed under the door.

Based on interview, the facility failed to ensure all staff members were familiar with fire drill procedures and able to respond to emergency situations. This was evidenced by staff members that could not locate the fire alarm pull box, the closest fire extinguisher, and the kitchen ansul sprinkler system pull device. Staff failed to know the code for fire, and to carry a key to activate the fire alarm on one unit. This could result in a delay in staff response to a fire.

NFPA 101 Life Safety Code, 2000 edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During a tour of the facility with staff, from July 9, through July 11, 2012, staff members were interviewed regarding fire drill procedures.

Between 9:00 a.m., and 5:00 p.m., twenty-two staff members were interviewed and asked to describe their actions if they discovered a facility fire or kitchen stove fire, to locate an alarm activation device or a fire extinguisher, and to describe the code for fire (code Red). Staff were asked to demonstrate that they had a key to activate a fire alarm on the lock down unit.

Three of twenty-two staff were unable to locate an alarm activation device, that was approximately 20 feet away. Two of twenty-two staff were unable to locate a fire extinguisher that was approximately 10 feet away. One of one staff in the Kitchen chose to utilize an ABC fire extinguisher on the stove instead of the K-Fire extinguisher that was near the stove. The K-Fire extinguisher is designed to be used on grease type fires. This kitchen staff was unable to locate the pull alarm activation device that was approximately 15 feet away and the ansul device which was approximately 12 feet away. One of twenty-two staff could not locate a key to activate a fire alarm on the lock down unit. Two of twenty-two staff did not know the code phrase for fire (code red).

Based on observation, and interview, the facility failed to maintain the integrity of their fire alarm system in accordance with NFPA 72. This was evidenced by the failure of one smoke detector and one fire alarm chime. This could result in a potential delay in notifying the occupants of a fire, and affected patients in 1 of 17 smoke compartments in the East Campus and 1 of 6 smoke compartments on the first floor in the Tower Building.

NFPA 72, National Fire Alarm Code (1999 Edition)
Chapter 7 Inspection, Testing, and Maintenance
7-1.1.2 System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner ' s designated representative shall be informed of the impairment in writing within 24 hours.

Findings:

During fire alarm testing with the Plant Maintenance Manager, Plant Operations Manager, Facility Management Director and Director of Public Safety on July 10, 2012 and July 11, 2012, the fire alarm system was tested and observed.

East Campus on 7/11/12
1. At 10:32 a.m., the chime at the end of the East Campus Lobby corridor failed to activate an audible alarm during fire alarm testing.


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Tower on 7/10/12
2. At 1:55 p.m., the South smoke detector (one of two), failed to activate when tested with canned smoke, in the Emergency Room Nursing Station. The red light was on but no alarm was activated. Three attempts were made without activating the fire alarm system.

At 1:56 p.m., the Plant Maintenance Manager asked TRL (fire alarm repair company) to explain what is going on with the smoke detector that failed. The person from TRL stated during an interview "the smoke detector is not connected to the alarm system. It should have been disconnected and taken down."

Based on observation, the facility failed to maintain their portable fire extinguishers in accordance with NFPA 10. This was evidenced by a portable fire extinguisher that was obstructed from immediate access and view. This affected patients in 1 of 6 smoke compartments on the first floor Tower Building, and could result in a delay to access the fire extinguisher in the event of a fire.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

Findings:

During a tour of the facility with the Facilities Management Director, and the Director of Public Safety, on July 9, 2012, the portable fire extinguishers were observed in the Tower building.

At 2:39 p.m., the fire extinguisher outside of the stress lab was impeded from access and obstructed from view. There was an approximately 6 foot by 5 foot privacy screen in front of the fire extinguisher.

Based on observation and interview, the facility failed to maintain their electrical equipment and utilities. This was evidenced by high powered appliances plugged into surge protectors, by a surge protector plugged into a surge protector, by broken or missing electrical receptacle cover plates, and by missing circuit cover blanks and unlabeled circuit breakers. This affected 4 of 20 smoke compartments in the Tower Building and 2 of 17 smoke compartments in the East Campus Building. This failure could result in the potential increase of an electrical fire, resulting in potential harm to patients, staff and visitors.

NFPA 70, National Electrical Code, 1999 edition
384-13. General. All panel boards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panel boards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer's name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panel board circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or board.

400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

410-56(e), After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:

During a tour of the facility with the Plant Maintenance Manager, the Plant Operations Manager, the Facility Management Director, and the Public Safety Director, on July 9, 2012, and July 10, 2012, the electrical equipment and wiring were observed.

Tower on 7/9/12
1. At 1:42 p.m., the electrical outlet in the corridor next to Room 402 was broken at the ground port.

2. At 1:58 p.m., the electrical cover plate was broken in Room 416.

East Campus on 7/10/12
3. At 10:17 a.m., the blank covers were missing for circuit 33 and 35 in Panel EM1-2 that is located in the Staffing office.


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Tower First floor on 7/9/12
4. At 2:45 p.m., in the Director of Cardiac Pulmonary Office, a refrigerator was plugged into a surge protector and not directly into an electrical outlet.

5. At 3:04 p.m., in the Emergency Room Manager's Office, a refrigerator was plugged into surge protector and not directly into the wall outlet.

6. At 3:07 p.m., a surge protector was plugged into another surge protector, under the north side of the desk at the Emergency Room Nursing Station.

East Campus on 7/10/12
7. At 9:51 a.m., in the Physical Plant Locker Room/Server Room, the circuit panel (Panel EMO-PNL) had 3 of 42 circuit breakers in the on position that were unlabeled. Circuits 31, 36, and 42 were not identified.

8. At 9:58 a.m., in the facility plant Maintenance Shop, the circuit panel (Panel AM-10) had 10 of 31 circuit breakers in the on position that were unlabeled. Circuits 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 were not identified.

During an interview at 9:59 a.m., the Plant Maintenance Manager stated he did not know what those (referring to the 10 unidentified circuits in Panel AM-10) were connected to.

Based on observation, the facility failed to maintain the Alcohol Based Hand Rub (ABHR) dispensers, as evidenced by a dispenser installed adjacent to an ignition source. This affected 1 of 6 smoke compartments on the first floor of the Tower Building and had the potential for a fire.

NFPA 30 Flammable and Combustible Liquids (1996 Edition) 4-8.5 Control of Ignition Sources. Precautions shall be taken to prevent the ignition of flammable vapors. Sources of ignition include, but are not limited to: open flames; lightning; smoking; cutting or welding; hot sources; frictional heat; static electricity; electrical or mechanical sparks; spontaneous heating, including heat-producing chemical reactions; and radiant heat.

Findings:

During the facility tour with the Plant Maintenance Manager, Plant Operations Manager, and Public Safety Director, from July 9, 2012, through July 11, 2012, the ABHR dispensers were observed.

Tower on 7/9/12
At 3:29 p.m., the ABHR dispenser located in the gift shop storage room was mounted above a light switch.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by failing to repair and seal penetrations to prevent the spread of fire and smoke. This failure affected patients, staff and visitors in 3 of 17 smoke compartments in the East Campus.

Findings:

During a tour of the facility with the Plant Maintenance Manager, Plant Operations Manager, Director of Public Safety and Safety Officer, from July 9, 2012 through July 12, 2012, the facility walls and ceilings were observed.

East Campus on 7/9/12
1. At 4 p.m., there was an approximately 1/2 inch penetration around two blue wires in the left side of the ceiling in the Pediatrics Medication Room.

East Campus on 7/10/12:
2. At 9:45 a.m., there was an approximately 1 inch unsealed penetration around blue and white wires, in the right comer of the ceiling, in the NCU (Nursing Care Unit) copy machine room.

3. At 9:54 a.m., there were two approximately 1/2 inch penetrations in the left side of the ceiling in the Payroll office, located in the Finance Department.

Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke, as evidenced by corridor doors that failed to latch or were obstructed from closing. This affected 4 of 20 smoke compartments in the Tower Building and 3 of 17 smoke compartments in the East Campus. This failure had the potential to allow the spread of smoke, which could result in potential harm to patients, staff and visitors.

Findings:

During the facility tour with the Facility Management Director, Director of Quality Management, Director of Public Safety, Plant Operations Manager and Plant Maintenance Manager from July 9, 2012 through July 11, 2012, the corridor doors were observed.

East Campus on 7/9/12
1. At 3:32 p.m., the door to Room 911 failed to latch when closed.

East Campus on 7/11/12
2. At 9:24 a.m., the door to Room 718 failed to latch when closed.

3. At 9:38 a.m., the door to Room 703 failed to latch. The door hit the side of the door jam and could not be fully closed.


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Tower on 7/9/11
4. At 1:32 p.m., the door to Room 309 did not close and latch when tested. The door struck the door frame and was obstructed from closing.

At 1:33 p.m., during an interview, the Facilities Management Director stated "The door is hitting the door frame."

5. At 2:55 p.m., the CT supply room door, on the first floor, was equipped with a self closing device. The door did not latch when tested. Three attempts were made without the door latching.

At 2:56 p.m., the Plant Manager stated during an interview "the door is not latching."

East Campus on 7/10/12
6. At 9:28 a.m., the door to the Intake Office, in Behavioral Health East, was equipped with a self closing device. The door did not latch in five attempts.

At 9:29 a.m., the Plant Manager stated during an interview "the door is not latching."

Tower on 7/10/11
7. At 1:49 p.m., the door to Room 6 in ICU 1 was impeded from closing. A laundry cart was in front of the door.

8. At 2:22 p.m., the door to ACU-2, in Outpatient Surgery, second floor, was impeded from closing. A bed was in front of the door.

Based on observation, the facility failed to ensure horizontal exit doors, on magnetic hold open devices, release and close automatically during activation of the fire alarm system. This was evidenced by a horizontal exit door that failed to release from its magnetic device. This affected 1 of 17 smoke compartments in the East Campus Building. This failure could result in the spread of fire and smoke from one compartment to another.

Findings:

During fire alarm system testing, with the Plant Maintenance Manager, Plant Operations Manager, Facility Management Director, and Director of Public Safety, on July 11, 2012, the doors on magnetic devices were observed.

East Campus on 7/11/12
At 10:20 a.m., the corridor door to the Activity room for Neuro Care West failed to release from its hold open device, after activation of the fire alarm system.

Based on observation and interview, the facility failed to maintain their exit signs in accordance with regulations. This was evidenced by an exit sign that failed to illuminate when tested on battery power. This could delay egress in 1 of 5 smoke compartments on the third floor in the Tower Building, causing potential harm to patients and staff in the event of a fire emergency.

NFPA 101 Life Safety Code, 2000 edition
7.10.5 Illumination of Signs.
7.10.5.1* General. Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests
shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency
lighting equipment that automatically performs a test for not less than
30 seconds and diagnostic routine not less than once every 30 days
and indicates failures by a status indicator shall be exempt from the
30-day functional test, provided that a visual inspection is performed
at 30-day intervals.

Findings:

During a tour of the facility with the Facilities Management Director, and Director of Quality Management, on July 9, 2012, the exit signs were observed in the Tower.

Tower on 7/9/12
At 1:50 p.m., the exit sign near Room 306 did not illuminate when the test button was pressed.

During an interview at 1:51 p.m., the Facilities Management Director confirmed the sign did not light up when the test button was pushed.

Based on observation and interview, the facility failed to maintain the integrity of the smoke barrier walls. This was evidenced by penetrations in 4 of 20 smoke barrier walls in the Tower Building. This had the potential to allow the spread of fire and smoke, during a fire.

NFPA 101, Life Safety Code (2000 Edition)
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with facility staff, on July 9, 2012, the smoke barrier walls were observed in the Tower building.

Tower on 7/9/12
1. At 2:23 p.m., there was an approximately 1 inch penetration around a conduit, in the smoke barrier wall next to Room 214. The area inside of the conduit was not sealed. This was confirmed by the Plant Maintenance Manager during the survey.

2. At 2:32 p.m., there was an approximately 1 inch by 2 inch penetration in the center of the smoke barrier wall located outside of NICU.

3. At 2:48 p.m., there were penetration around four conduits in the Surgery entrance side of the smoke barrier wall. This was confirmed by the Plant Maintenance Manager during the survey.


26387

4. At 1:59 p.m., there was an approximately 3/4 inch unsealed conduit in the North smoke barrier wall, above the fire doors, on the third floor near the service elevator C.

Based on observation and interview, the facility failed to maintain its smoke barrier (cross-corridor) doors to prevent the spread of smoke and fire. This was evidenced by smoke barrier fire doors that were equipped with latching hardware, and failed to latch when tested. This deficient practice could result in the spread of smoke and fire. This could affect patients, staff and visitors in 4 of 17 smoke compartments on the East Campus and 1 of 20 smoke compartments in the Tower Building.

Findings:

During fire alarm testing with facility staff, on July 10, 2012 and July 11, 2012, the smoke barrier doors were observed.

East Campus, First floor
1. At 9:53 a.m., the North leaf of the smoke barrier doors near Birth Records, on the first floor, did not latch when tested by the Plant Maintenance Manager.

At 9:54 a.m., the Plant Maintenance Manager stated during an interview, "the latching mechanism is sticking."

East Campus, First Floor
2. At 10:42 a.m., the Activity Therapy smoke barrier door in BHS East, did not latch when tested by the Plant Maintenance Manager.

East Campus, First floor
3. At 10:50 a.m., the East smoke barrier door, near the first floor Gym, did not latch when tested by the Plant Maintenance Manager.

Tower, First floor
4. At 2:30 p.m., the West smoke barrier door, at the South Lobby entrance, did not latch when tested by the Plant Maintenance Manager.

Based on observation, the facility failed to maintain the gift shop storage room door to resist the passage of smoke. This was evidenced by one door that was impeded from closing. This affected 1 of 6 smoke compartments on the first floor of the Tower Building and had the potential to allow the spread of smoke and fire.

Findings:

During the facility tour with staff, on July 9, 2012, the Tower gift shop storage room was observed.

At 3:26 p.m., the door to the storage room was impeded from closing. A brown rubber wedge was placed under the door.

Based on interview, the facility failed to ensure all staff members were familiar with fire drill procedures and able to respond to emergency situations. This was evidenced by staff members that could not locate the fire alarm pull box, the closest fire extinguisher, and the kitchen ansul sprinkler system pull device. Staff failed to know the code for fire, and to carry a key to activate the fire alarm on one unit. This could result in a delay in staff response to a fire.

NFPA 101 Life Safety Code, 2000 edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During a tour of the facility with staff, from July 9, through July 11, 2012, staff members were interviewed regarding fire drill procedures.

Between 9:00 a.m., and 5:00 p.m., twenty-two staff members were interviewed and asked to describe their actions if they discovered a facility fire or kitchen stove fire, to locate an alarm activation device or a fire extinguisher, and to describe the code for fire (code Red). Staff were asked to demonstrate that they had a key to activate a fire alarm on the lock down unit.

Three of twenty-two staff were unable to locate an alarm activation device, that was approximately 20 feet away. Two of twenty-two staff were unable to locate a fire extinguisher that was approximately 10 feet away. One of one staff in the Kitchen chose to utilize an ABC fire extinguisher on the stove instead of the K-Fire extinguisher that was near the stove. The K-Fire extinguisher is designed to be used on grease type fires. This kitchen staff was unable to locate the pull alarm activation device that was approximately 15 feet away and the ansul device which was approximately 12 feet away. One of twenty-two staff could not locate a key to activate a fire alarm on the lock down unit. Two of twenty-two staff did not know the code phrase for fire (code red).

Based on observation, and interview, the facility failed to maintain the integrity of their fire alarm system in accordance with NFPA 72. This was evidenced by the failure of one smoke detector and one fire alarm chime. This could result in a potential delay in notifying the occupants of a fire, and affected patients in 1 of 17 smoke compartments in the East Campus and 1 of 6 smoke compartments on the first floor in the Tower Building.

NFPA 72, National Fire Alarm Code (1999 Edition)
Chapter 7 Inspection, Testing, and Maintenance
7-1.1.2 System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner ' s designated representative shall be informed of the impairment in writing within 24 hours.

Findings:

During fire alarm testing with the Plant Maintenance Manager, Plant Operations Manager, Facility Management Director and Director of Public Safety on July 10, 2012 and July 11, 2012, the fire alarm system was tested and observed.

East Campus on 7/11/12
1. At 10:32 a.m., the chime at the end of the East Campus Lobby corridor failed to activate an audible alarm during fire alarm testing.


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Tower on 7/10/12
2. At 1:55 p.m., the South smoke detector (one of two), failed to activate when tested with canned smoke, in the Emergency Room Nursing Station. The red light was on but no alarm was activated. Three attempts were made without activating the fire alarm system.

At 1:56 p.m., the Plant Maintenance Manager asked TRL (fire alarm repair company) to explain what is going on with the smoke detector that failed. The person from TRL stated during an interview "the smoke detector is not connected to the alarm system. It should have been disconnected and taken down."

Based on observation, the facility failed to maintain their portable fire extinguishers in accordance with NFPA 10. This was evidenced by a portable fire extinguisher that was obstructed from immediate access and view. This affected patients in 1 of 6 smoke compartments on the first floor Tower Building, and could result in a delay to access the fire extinguisher in the event of a fire.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

Findings:

During a tour of the facility with the Facilities Management Director, and the Director of Public Safety, on July 9, 2012, the portable fire extinguishers were observed in the Tower building.

At 2:39 p.m., the fire extinguisher outside of the stress lab was impeded from access and obstructed from view. There was an approximately 6 foot by 5 foot privacy screen in front of the fire extinguisher.

Based on observation and interview, the facility failed to maintain their electrical equipment and utilities. This was evidenced by high powered appliances plugged into surge protectors, by a surge protector plugged into a surge protector, by broken or missing electrical receptacle cover plates, and by missing circuit cover blanks and unlabeled circuit breakers. This affected 4 of 20 smoke compartments in the Tower Building and 2 of 17 smoke compartments in the East Campus Building. This failure could result in the potential increase of an electrical fire, resulting in potential harm to patients, staff and visitors.

NFPA 70, National Electrical Code, 1999 edition
384-13. General. All panel boards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panel boards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer's name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panel board circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or board.

400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

410-56(e), After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:

During a tour of the facility with the Plant Maintenance Manager, the Plant Operations Manager, the Facility Management Director, and the Public Safety Director, on July 9, 2012, and July 10, 2012, the electrical equipment and wiring were observed.

Tower on 7/9/12
1. At 1:42 p.m., the electrical outlet in the corridor next to Room 402 was broken at the ground port.

2. At 1:58 p.m., the electrical cover plate was broken in Room 416.

East Campus on 7/10/12
3. At 10:17 a.m., the blank covers were missing for circuit 33 and 35 in Panel EM1-2 that is located in the Staffing office.


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Tower First floor on 7/9/12
4. At 2:45 p.m., in the Director of Cardiac Pulmonary Office, a refrigerator was plugged into a surge protector and not directly into an electrical outlet.

5. At 3:04 p.m., in the Emergency Room Manager's Office, a refrigerator was plugged into surge protector and not directly into the wall outlet.

6. At 3:07 p.m., a surge protector was plugged into another surge protector, under the north side of the desk at the Emergency Room Nursing Station.

East Campus on 7/10/12
7. At 9:51 a.m., in the Physical Plant Locker Room/Server Room, the circuit panel (Panel EMO-PNL) had 3 of 42 circuit breakers in the on position that were unlabeled. Circuits 31, 36, and 42 were not identified.

8. At 9:58 a.m., in the facility plant Maintenance Shop, the circuit panel (Panel AM-10) had 10 of 31 circuit breakers in the on position that were unlabeled. Circuits 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 were not identified.

During an interview at 9:59 a.m., the Plant Maintenance Manager stated he did not know what those (referring to the 10 unidentified circuits in Panel AM-10) were connected to.